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Background The aim of this study was to evaluate prognostic value of body tissue composition at the upper thigh level for 1 year mortality in elderly patients with proximal femur fracture. Methods This retrospective cohort study included consecutive elderly (aged ≥65) patients diagnosed with proximal femur fracture based on the findings of pelvic bone computed tomography (CT) performed at the emergency department of a tertiary care hospital and treated with surgery between 2010 and 2017. The cross‐sectional area of subcutaneous fat and skeletal muscle at the upper thigh level was measured using CT. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for 1 year mortality were estimated using a Cox proportional hazards model. Survival based on the SFA quartiles was assessed using nonparametric Kaplan–Meier survival analysis and compared used log‐rank tests. Results Among 876 elderly patients included in this study, the median age was 79.0 years, and 646 (73.7%) patients were female. A total of 93 (10.6%) died within 1 year after admission to the emergency department. Survivors had a significantly higher median subcutaneous fat area (SFA) than non‐survivors (170.2 vs. 133.0 cm2, P 195.0 cm2) quartiles showed significantly longer survival duration than those with SFA in the first (

Background Previously conducted physician-centered trials on the usefulness of vasopressin have yielded negative results; thus, patient-oriented trials have been warranted. We hypothesize that Augmented-Medication CardioPulmonary Resuscitation could be helpful for selected patients with out-of-hospital cardiac arrest (OHCA). Methods This is a double-blind, single-center, randomized, placebo-controlled trial conducted in the emergency department in a tertiary, university-affiliated hospital in Seoul, Korea. A total of 148 adults with non-traumatic OHCA who had initial diastolic blood pressure (DBP) Results Of the 180 included patients, 32 were excluded, and 148 were enrolled in the trial. A sustained return of spontaneous circulation was achieved by 27 patients (36.5%) in the vasopressin group and 24 patients (32.4%) in the control group (risk difference, 4.1%; P = .60). Survival discharge and good neurologic outcomes did not differ between groups. The trial group had significantly higher median DBPs during resuscitation than the control group (16.0 vs. 14.5 mm Hg, P Conclusion Among patients with refractory vasodilatory shock in OHCA, administration of vasopressin, compared with placebo, did not significantly increase the likelihood of return of spontaneous circulation.

The utilization of the emergency department (ED) has been continuously increasing and has become a burden for ED resources. The aim of this study was to describe the characteristics, outcomes, common diagnoses, and disease classifications of patients who were referred to the ED. This nationwide epidemiologic study examined the data from adult patients (>18 years) who visited EDs from 1 January 2016 to 31 December 2018. Most EDs in Korea provide data from ED patients to the National Emergency Medical Center (NEMC). The disposition of ED patients was classified as discharge, admission, death, and re-transfer. From 2016 to 2018, the proportion of referred patients out of the total ED visits increased from 7.3% to 7.8%. The referred patients were older (61.1 vs. 50.5 years), had worse vital signs, longer ED lengths of stay (409.1 vs. 153.3 min), and higher admission (62.3 vs. 16.9%) and re-transfer rates (4.4 vs. 1.9%) than the direct-visit patients. Among the referred patients in the 3 years, 62.3% were hospitalized, and the most common disease classification was “disease of the digestive system” (19.8%). The most common diagnosis was pneumonia (6.0%), followed by urinary tract infection, gastrointestinal bleeding, and hepatobiliary infection. The number of patients referred to EDs is increasing, and more than 60% of referred patients are hospitalized. Detailed characteristics of these patients will be helpful for improving ED management and the distribution of medical resources.

The HEART (history, ECG, age, risk factors, troponin) pathway (HP) was developed for identifying low-risk patients for early discharge among patients presenting with chest pain to the emergency department (ED). We investigated whether adding coronary computed tomography angiography (CCTA) results to selected patients could improve the diagnostic accuracy of the HP. Patients suspected of acute coronary syndrome who had undergone CCTA were included. The HP was modified by adding CCTA results of stenosis of any major epicardial coronary arteries to patients either with 0-3 points and a positive troponin test or with 4-6 points. All patients were reclassified into low and increased risk groups. We then compared the accuracy of the modified HP, the HP, and the HEART score. The primary outcome was the 30-day major adverse cardiac events (MACE). Of the total 1239 patients included, MACE occurred in 206 (16.6%) patients. Adding the CCTA results increased the proportion of patients with low risk (68.7%) compared with the HP (40.0%) and the HEART score (47.4%). Using the modified HP, 50.4% of patients with intermediate-risk by the HEART score could be discharged from the ED and had no MACE. Incorporation of CCTA results improved the accuracy rate for the prediction of MACE compared with the HP and the HEART score (net reclassification improvements were 34.5 and 39.6%, respectively). Using the CCTA after the HP in selected patients could be a better strategy to discharge more patients early and safely.

Background/Aims Among patients with febrile neutropenia that developed after chemotherapy, high-risk patients, such as those having clinical instability or Multinational Association of Supportive Care in Cancer score of < 21, require hospitalization for intravenous empiric antibiotic therapy. Monotherapy with an anti-pseudomonal ß-lactam agent is recommended. Although many studies reported the microbial etiology of infections and resistant patterns of febrile neutropenia, the patients were not well characterized as having neutropenic septic shock. Therefore, this study aimed to determine the microbial spectrum of infections and resistance patterns of their isolates in patients with chemotherapy-induced neutropenic septic shock. Methods Data of adult patients diagnosed with neutropenic septic shock in the emergency department between June 2012 and December 2016 were extracted from a prospectively compiled septic shock registry at a single academic medical center. Thereafter, microbiological studies and antimicrobial susceptibility tests were conducted. Results In total, 109 bacteria were found in patients with neutropenic septic shock. Gram-negative bacteria were the predominant causative organisms (84, 77.1%). Moreover, 33 microorganisms (30.3%) were multidrug-resistant (MDR) bacteria with extended-spectrum ß-lactamase-producing Escherichia coli (17, 50%) being the commonest. The most commonly affected sites in patients with MDR bacterial infections were the gastrointestinal tract (45%) and unknown (43.5%). Approximately 48.5% of MDR bacteria were resistant to cefepime but not to piperacillin- tazobactam or carbapenem. Conclusions MDR bacteria were prevalent in patients with chemotherapy-induced neutropenic septic shock. Therefore, piperacillin-tazobactam or carbapenem may be considered as empiric antibiotics if MDR bacteria are suspected to be causative agents.

Background Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. Methods This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. Results We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). Conclusion The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers., Graphical Abstract

BACKGROUND Emergency department (ED) utilization and emergency admissions by patients with cancer have increased. The authors aimed to evaluate the characteristics of patients with cancer admitted through the ED and determine whether cancer types are related to in-hospital mortality. METHODS The National Emergency Department Information System database of patients visiting EDs in South Korea between 2016 and 2017 was analyzed. Among 6,179,088 adult patients who presented to an ED with nontraumatic medical illness, patients with cancer were identified. The primary outcome was in-hospital mortality. RESULTS Patients with cancer accounted for 6.8% of ED visits, and 239,630 patients (57.0%) were admitted to the hospital (intensive care unit [ICU], 9.5%; others, 90.5%). The prevalent cancers requiring hospitalization were lung cancer (15.7%), liver cancer (14.2%), and colon cancer (11.6%). The commonest reasons for admission other than cancer-related medical problems (41.4%) were pneumonia (4.8%) and hepatobiliary infection (2.8%). Overall in-hospital mortality was 16.1% (ICU, 28.3%; general wards, 14.8%); lung cancer (22.9%), liver cancer (19.7%), and leukemia/multiple myeloma (17.8%) showed the highest mortality rates. The highest odds for mortality were for lung cancer (adjusted odds ratio [OR], 2.227; 95% confidence interval [CI], 2.124-2.335; P < .001) and liver cancer (adjusted OR, 1.839; 95% CI, 1.751-1.930; P < .001), which were referenced to genitourinary cancer by multivariable logistic regression analysis. CONCLUSIONS More than half of the patients with cancer visiting EDs were admitted to the hospital with a mortality rate of 16.1%. Physicians treating patients with cancer and policymakers and planners designing health systems should understand the different prevalences and outcomes of oncological emergencies by cancer type to improve patient care.

Diagnosing stroke in patients experiencing dizziness without neurological deficits is challenging for physicians. This study tried to evaluate the prevalence of acute stroke in patients who presented with isolated dizziness without neurological deficits at the emergency department (ED), and determine the relevant stroke predictors in this population. This was an observational, retrospective record review of consecutive 2,215 adult patients presenting with dizziness at the ED between August 2019 and February 2020. Multivariate analysis was performed to identify risk factors for acute stroke. 1,239 patients were enrolled and analyzed. Acute stroke was identified in 55 of 1,239 patients (4.5%); most cases (96.3%) presented as ischemic stroke with frequent involvement (29.1%) of the cerebellum. In the multivariate analysis, the history of cerebrovascular injury (odds ratio [OR] 3.08 [95% confidence interval {CI} 1.24 to 7.67]) and an age of > 65 years (OR 3.01 [95% CI 1.33 to 6.83]) were the independent risk factors for predicting acute stroke. The combination of these two risks showed a higher specificity (94.26%) than that of each factor alone. High-risk patients, such as those aged over 65 years or with a history of cerebrovascular injury, may require further neuroimaging workup in the ED to rule out stroke.

Precise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps Ps

Drug repositioning is an effective way to mitigate the production problem in the pharmaceutical industry. Electronic medical record (EMR) databases harbor a large amount of data on drug prescriptions and laboratory test results and may thus be useful for finding new indications for existing drugs. Here, we present a novel high-throughput data-driven algorithm that identifies and prioritizes drug candidates that show significant effects on specific clinical indicators by utilizing large-scale EMR data. We chose four laboratory tests as clinical indicators: hemoglobin A1c (HbA1c), low-density lipoprotein (LDL) cholesterol, triglycerides (TGs), and high-density lipoprotein (HDL) cholesterol. From a 5-year EMR database, we generated datasets consisting of paired data with averaged measurement values during on and off each drug in each patient, adjusted for co-administered drug effects at each timepoint, and applied one sample t-test with the Bonferroni correction for statistical analysis. Among 1,774 drugs, 45 were associated with increases in HDL cholesterol, and 41, 146, and 65 were associated with reductions in HbA1c, LDL cholesterol, and TGs, respectively. We compared the list of candidate drugs with that of drugs indicated for relevant clinical conditions and found that the algorithm had high values for both sensitivity (range 0.95-1.00) and negative predictive value (range 0.95-1.00). Our algorithm was able to rediscover well-known drugs that are used for diabetes and dyslipidemia while revealing potential candidates without current indications but have shown promising results in the literature. Our algorithm may facilitate the repositioning of drugs with proven safety profiles.

Accurate risk stratification for obstructive coronary artery disease (CAD) and major cardiac adverse events (MACE) is important in emergency departments. We compared six established chest pain risk scores (the HEART score, CAD basic model, CAD clinical model, TIMI, GRACE, uDF) for prediction of obstructive CAD and MACE.Patients who presented to the emergency department with chest pain or symptoms of suspected CAD and underwent coronary computed tomographic angiography were analyzed. The primary endpoint was adverse outcomes including the presence of obstructive CAD (≥50% stenosis) and the occurrence of MACE within 6 weeks. We compared the risk scores by the area under the receiver-operating characteristic curve (AUC) and calculated their respective net reclassification index (NRI).Adverse outcomes occurred in 285 (28.4%) out of the 1002 patients included. For the prediction of adverse outcomes, the AUC of the HEART score (0.792) was superior to those of the CAD clinical model (0.760), CAD basic model (0.749), TIMI (0.749), uDF (0.703), and GRACE (0.653). In terms of the NRI, the HEART score significantly improved the reclassification abilities of the uDF (0.39), GRACE score (0.27), CAD basic model (0.11), TIMI (0.10), and CAD clinical model (0.08) (all P 0.05). The HEART score also had the highest negative predictive value as well (0.893).The HEART score was superior to other cardiac risk scores in predicting both obstructive CAD and MACE. However, due to the high false-negative rate (11%) of the HEART score, its use for identifying low-risk patients should be considered with caution.

Background We hypothesised that lactate concentrations are independently associated with massive transfusion in patients with primary postpartum haemorrhage. Moreover, combining lactate concentrations with the shock index, defined as the ratio of heart rate to systolic arterial blood pressure, can improve the predictive performance for massive transfusion. Methods We retrospectively analysed patients with primary postpartum haemorrhage in the emergency department of a tertiary referral centre in Korea between January 1, 2004 and December 31, 2015. Results Of the 302 patients, 101 (33.4%) patients required massive transfusion. Lactate concentration was independently associated with the requirement for massive transfusion [odds ratio, 1.56; 95% confidence interval (CI), 1.31–1.87; P 4.0 mM L−1) was associated with 86.1% specificity and 67.8% positive predictive value for massive transfusion. When combining elevated lactate concentrations (>4.0 mM L−1) with a shock index >1.0, the specificity and positive predictive value increased to 95.5% and 82.4%, respectively. Conclusions Point-of-care testing of lactate concentrations in the emergency department may be useful to predict massive transfusion requirements in primary postpartum haemorrhage. Combining initial lactate concentrations with the shock index improves the predictive performance for massive transfusion requirements and may contribute to rapid risk stratification of patients with primary postpartum haemorrhage in need of transfusion and further focus on early interventions to control bleeding.

A decrease in skeletal muscle mass has been shown to increase hospital mortality. Nevertheless, little is known about the association between progressive muscle loss over time and clinical outcomes. We aimed to evaluate whether progressive loss of muscle mass in septic shock patients was associated with mortality. We reviewed prospectively enrolled registry of septic shock which had 817 consecutive patients. Of these, 175 patients who had computed tomography (CT) at a time of admission as well as 3–6 months prior to admission were included. Between these two CTs, the change in total abdominal muscle area index (TAMAI) was evaluated for progressive muscle loss. The change in TAMAI was higher in the non-survivors (−7.6 cm2/m2, 19.0% decrease) than the survivors (−4.0 cm2/m2, 10.5% decrease) with statistical significance (p = 0.002). Multiple logistic regression showed that the patients who had more than a 6.4 cm2/m2 (16.7%) reduction of TAMAI had a 4.42-fold higher risk for mortality at 28 days (OR, 4.42; 95% CI, 1.41–13.81, p = 0.011). Our study suggested that progressive loss of muscle mass might be a useful prognostic factor for septic shock patients. This implication will need to be further explored in future prospective studies.

The detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI.This retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients.A total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06-8.34; P 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08-9.23; P 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01-1.04; P = 0.002) were independent risk factors for concomitant intracranial injury.Emergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age.

We investigated clinical outcomes in high-risk patients with acute nonvariceal upper gastrointestinal bleeding (UGIB), and determined if urgent endoscopy is effective.Consecutive patients with a Glasgow-Blatchford score greater than 7 who underwent endoscopy for acute nonvariceal UGIB at the emergency department from January 1, 2005, to December 31, 2014, were included. Urgent (6 h) and elective (6-48 h) endoscopies were defined according to the time to endoscopy after the initial presentation. The primary outcomes were mortality and rebleeding within 28 days of admission.Among 961 patients, 571 patients underwent urgent endoscopy. The 28-day mortality rate was 2.5%, and the rebleeding rate was 10.4%. There were significant differences in mortality rate (1.6% vs 3.8%), the number of transfused packed red blood cells (2.6 ± 2.5 vs 2.3 ± 2.1 packs), need for intervention (69.5% vs 53.5%), and embolization (2.8% vs 0.5%), but no differences in rebleeding, intensive care unit admission, vasopressor use, and length of stay between the urgent and elective endoscopy groups. Mortality was associated with malignancy (odds ratio [OR], 3.58; 95% confidence interval [CI], 1.33-9.62), cirrhosis (OR, 4.67; 95% CI, 1.85-11.76), urgent endoscopy (OR, 0.36; 95% CI, 0.14-0.95), failed primary endoscopic treatment (OR, 15.03; 95% CI, 4.63-48.82), and rebleeding (OR, 2.77; 95% CI, 1.03-7.45). Rebleeding was associated with Forrest I ulcers (OR, 7.67; 95% CI, 2.71-21.69), Forrest II ulcers (OR, 2.34; 95% CI, 1.51-3.60), and coagulopathy (OR, 2.34; 95% CI, 1.51-3.60).Urgent endoscopy was an independent predictor of lower mortality rate but was not associated with rebleeding in high-risk patients with acute nonvariceal UGIB.

Background/Aims: The aim of this study was to compare the effects of erythromycin infusion and gastric lavage in order to improve the quality of visualization during emergency upper endoscopy. Methods: We performed a prospective randomized pilot study. Patients presented with hematemesis or melena within 12 hours and were randomly assigned to the erythromycin group (intravenous infusion of erythromycin), gastric lavage group (nasogastric tube placement with gastric lavage), or erythromycin + gastric lavage group (both erythromycin infusion and gastric lavage). The primary outcome was satisfactory visualization. Secondary outcomes included identification of a bleeding source, the success rate of hemostasis, duration of endoscopy, complications related to erythromycin infusion or gastric lavage, number of transfused blood units, rebleeding rate, and bleeding-related mortality. Results: A total of 43 patients were randomly assigned: 14 patients in the erythromycin group; 15 patients in the gastric lavage group; and 14 patients in the erythromycin + gastric lavage group. Overall satisfactory visualization was achieved in 81% of patients: 92.8% in the erythromycin group; 60.0% in the gastric lavage group; and 92.9% in the erythromycin + gastric lavage group, respectively (p = 0.055). The identification of a bleeding source was possible in all cases. The success rate of hemostasis, duration of endoscopy, and number of transfused blood units did not significantly differ between groups. There were no complications. Rebleeding occurred in three patients (7.0%). Bleeding-related mortality was not reported. Conclusions: Intravenous erythromycin infusion prior to emergency endoscopy for acute nonvariceal upper gastrointestinal bleeding seems to provide satisfactory endoscopic visualization.

The incidence of pyogenic liver abscess (PLA), a life-threatening condition, is increasing worldwide. This study was designed to evaluate clinical features and outcomes in initially stable patients with PLA and to determine the predictors of septic shock.The medical records of all adult patients who were hemodynamically stable and diagnosed with PLA in the emergency department from January 2010 to December 2014, inclusive, were reviewed. The primary outcome was septic shock.A review of medical records identified 453 patients (66.7% male), of mean age 61.4 years, diagnosed with PLA. Of these patients, 73 (16.1%) had septic shock and 10 (2.2%) died in-hospital. Of the 73 patients with septic shock, nine (12.3%) died in-hospital. The most common symptom was fever (79.5%), and the most common infectious agent was Klebsiella pneumoniae. Septic shock was significantly associated with age ≥60 years [odds ratio (OR): 2.99, 95% confidence interval (CI): 1.38-6.48], malignancy (OR: 2.11, 95% CI: 1.08-4.09), systolic blood pressure100 mmHg (OR: 3.63, 95% CI: 1.43-9.21), respiratory rate ≥24/min (OR: 3.15, 95% CI: 1.20-8.28) and lactate concentration ≥2 mmol/L (OR: 4.92, 95% CI: 2.51-9.64). Septic shock also tended to be associated with procalcitonin concentration, but this was not statistically significant (OR: 3.42, 95% CI: 0.96-12.18).Septic shock was frequent in initially stable patients with PLA and was associated with older age, malignancy, low blood pressure, tachypnea and elevated lactate concentration.

The association between long duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) and neurologic outcome is unclear and understudied with advancements in post-cardiac arrest care and high-quality cardiopulmonary resuscitation. We investigated how downtime, defined as the interval from collapse-to-return of spontaneous circulation (ROSC), impacts on neurologic outcome in OHCA patients treated with targeted temperature management (TTM).A multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adults (≥18 years) non-traumatic OHCA patients treated with TTM between January 2007 and December 2012 at these hospitals, we included 858 patients who had sufficient data for calculating downtime. Good neurologic outcome was defined as a cerebral performance category score of 1 or 2.Median downtime was 30.0 (22.0-41.0min) and 242 patients (28.2%) had good neurologic outcome. When downtime was divided by 10-min intervals (≤10min, 11-20min, 21-30min, 31-40min, 41-50min, 51-60min, and60min), their neurologically intact survival rate were 48.2%, 51.6%, 29.2%, 22.1%, 16.1%, 14.8%, and 7.1%, respectively (p=0.01). Although downtime was associated with poor neurologic outcome [odds ratio 1.06 (1.05-1.08), p0.01], the area under the receiver operating characteristic curve of downtime for outcome was only 0.67, 95% CI (0.63-0.71). Furthermore, even with downtime20min, 22.2% (150/526) patients still had a good neurologic outcome, and this percentage increased to 50.3% (93/185) in patients with an initial shockable rhythm, and 31.1% (134/431) with age65 years.We found that neurologically intact survival can occur at prolonged downtimes and were unable to identify a downtime for which survivability was clearly futile. These data suggest that downtime should not be considered as a factor in determining whether to provide aggressive post-arrest care, especially in patients with young patients or those with an initially shockable rhythm.

Acute bacterial meningitis is rare, but can be fulminant unless rapidly evaluated and treated. The aim of this study was to evaluate whether serum procalcitonin (PCT) levels could predict unfavorable outcomes of bacterial meningitis. We retrospectively reviewed the medical records of 604 meningitis patients from the emergency department (ED) of our tertiary care, university-affiliated hospital over a five-year period. We analyzed the ability of blood PCT levels on admission to predict the outcome at discharge (defined as Glasgow Outcome Scale scores of 1–4). Of 71 patients with acute bacterial meningitis, 28 (39 %) experienced an unfavorable outcome at discharge (overall mortality: 5 %). The serum PCT level at admission was a predictive indicator of an unfavorable outcome [adjusted odds ratio: 1.04, 95 % confidence interval (CI) 1.01–1.09, p = 0.05]. As assessed using receiver operating characteristic curves for an unfavorable outcome, the area under the PCT curve was 0.708 (95 % CI 0.58–0.84, p

Acquired methemoglobinemia is a potentially fatal condition that leads to tissue hypoxia. Although the clinical features of methemoglobinemia depend on the methemoglobin levels, the clinical course would differ depending on the causative agents.We attempted to clarify this issue by comparing the clinical course of methemoglobinemia caused by dapsone and that caused by other toxic agents.A retrospective case-control study was performed. All patients with methemoglobinemia and who were admitted to the emergency department (ED) of our hospital from 1 January 2002 to 31 December 2014 were included.Of the 34 patients with methemoglobinemia, 15 ingested dapsone (14 with acute overdose and one with chronic therapeutic use) and 19 had been exposed to other toxic agents, such as sodium nitrites, indoxacarb, primaquine, and lidocaine. The clinical characteristics and the course of dapsone-induced and other toxic-agent-induced methemoglobinemia were compared. There was no significant difference in clinical presentation and methemoglobin level (38.5% vs. 35.0%, p = 0.456) upon their ED arrival between the two groups. However, the methemoglobin level after use of methylene blue and the total dose of methylene blue were higher in patients with dapsone-induced methemoglobinemia than in those with other agent-induced methemoglobinemia (11.9% vs. 1.7%, p = 0.001, 455 mg vs. 144 mg, p = 0.006). The majority of dapsone-induced methemoglobinemia (93.3%) required more than 72 h for normalization of the methemoglobin level, despite the use of methylene blue. Five of the study patients died due to multiorgan failure, and all of whom were inpatients with dapsone-induced methemoglobinemia.The clinical course of dapsone-induced methemoglobinemia was worse than that of other toxic-agent-induced methemoglobinemia despite no significant difference in their initial clinical presentation. Continuous treatment with serial monitoring of the serum methemoglobin is necessary for patients with dapsone-induced methemoglobinemia.

Background : /Aims: The aim of this study was to identify the ability of Glasgow-Blatchford score (GBS) and pre-endoscopic Rockall score (pre-E RS) to predict the occurrence of hypotension in patients with non-variceal upper gastrointestinal bleeding who are initially normotensive at emergency department. Methods : : Retrospective observational study was conducted at Asan Medical Center emergency department (ED) in patients who presented with non-variceal upper gastrointestinal bleeding from January 1, 2011 to December 31, 2013. Study population was divided according to the development of hypotension, and demographics, comorbidities, and laboratory findings were compared. GBS and pre-E RS were estimated to predict the occurrence of hypotension. Results : : A total of 747 patients with non-variceal upper gastrointestinal bleeding were included during the study period, and 120 (16.1%) patients developed hypotesion within 24 hours after ED admission. The median values GBS and pre-E RS were statistically different according to the occurrence of hypotension (8.0 vs. 10.0, 2.0 vs. 3.0, respectively; p

Objective We aimed to develop and validate a deep learning system for fully automated segmentation of abdominal muscle and fat areas on computed tomography (CT) images. Materials and methods A fully convolutional network-based segmentation system was developed using a training dataset of 883 CT scans from 467 subjects. Axial CT images obtained at the inferior endplate level of the 3rd lumbar vertebra were used for the analysis. Manually drawn segmentation maps of the skeletal muscle, visceral fat, and subcutaneous fat were created to serve as ground truth data. The performance of the fully convolutional network-based segmentation system was evaluated using the Dice similarity coefficient and cross-sectional area error, for both a separate internal validation dataset (426 CT scans from 308 subjects) and an external validation dataset (171 CT scans from 171 subjects from two outside hospitals). Results The mean Dice similarity coefficients for muscle, subcutaneous fat, and visceral fat were high for both the internal (0.96, 0.97, and 0.97, respectively) and external (0.97, 0.97, and 0.97, respectively) validation datasets, while the mean cross-sectional area errors for muscle, subcutaneous fat, and visceral fat were low for both internal (2.1%, 3.8%, and 1.8%, respectively) and external (2.7%, 4.6%, and 2.3%, respectively) validation datasets. Conclusion The fully convolutional network-based segmentation system exhibited high performance and accuracy in the automatic segmentation of abdominal muscle and fat on CT images.

Patients with chemotherapy-induced febrile neutropenia (FN) are vulnerable to extended-spectrum b-lactamase-producing Enterobacteriaceae (ESBL-PE) infection. Early identification of patients suspected to have ESBL-PE infection for empirical carbapenem administration is crucial; nevertheless, risk factors for ESBL-PE causing septic shock remain unclear. We identify factors to predict ESBL-PE in septic shock patients with chemotherapy-induced FN. In this observational, prospectively collected registry-based study, consecutive adult chemotherapy-induced FN patients with septic shock who were admitted to the emergency department between June 2012 and June 2018 were enrolled. Clinical and laboratory data extracted from the septic shock registry were assessed to identify risk factors for ESBL-PE. Of 179 chemotherapy-induced FN septic shock patients, ESBL-PE is isolated in 23 (12.8%). ESBL-PE infection is frequently seen in patients with hepatobiliary cancer (17.4% vs. 4.5%, P = 0.037), leukemia (13.0% vs. 2.6%, P = 0.046), and those with profound neutropenia (defined as absolute neutrophil count

Perilla (Perilla frutescens) is a commonly consumed herb with various health benefits in Asia. However, the risks of food-borne illness owing to the presence of pathogens on perilla leaves have not been evaluated. In this study, we evaluated the microbiota of perilla leaves harvested in South Korea using Illumina MiSeq sequencing of the 16S rRNA gene. In total, 2,743,003 sequencing reads were obtained, and 92-437 operational taxonomic units were observed in all samples. Bacterial loads were quantified, and the diversity indices were compared. Differences in the microbiota among sampling times and regions were also investigated. Proteobacteria and Firmicutes were predominant phyla at both times. At the class level, the bacterial communities were composed primarily of Alphaproteobacteria, Bacilli, and Gammaproteobacteria. Diverse bacterial taxa, such as Bacillus, uncultured family Enterobacteriaceae, and Sphingomonas were detected, and the representative pathogenic species (i.e., Acinetobacter lwoffii, Klebsiella pneumoniae, and Staphylococcus aureus) were quantified by qRT-PCR. The results of the co-occurrence network analysis showed characteristics of bacterial taxa in the microbiome on perilla leaves and provided insights into the roles of correlations among diverse microbes, including potential pathogens. Based on these results, the potential risk of food-borne illness from consumption of perilla leaves may be higher in July than in April. In summary, the microbial compositions determined in this study can be used as a base data for food-safety management for prediction and prevention of future outbreaks.

OBJECTIVES Objective screening tool for patients at a high risk of developing acute brain injury (ABI) is necessary for the proper treatment of carbon monoxide (CO) poisoning patients. The aim of this study is to identify clinical factors that could predict ABI due to CO poisoning in patients with an altered mental status. METHODS A prospectively collected CO poisoning registry at a single academic medical center was retrospectively analyzed. CO poisoning patients with an altered mental status at the emergency department, defined as unalert on the alert/responsive to voice/responsive to pain/unresponsive scale and underwent diffusion-weighted magnetic resonance imaging (DW-MRI) between January 1, 2013, and December 31, 2015, were included. ABI was defined as the presence of acute hypoxic brain lesions. Clinical predictors of ABI were identified by multivariate logistic regression analysis. RESULTS Of 180 patients, 67 (37.2%) had ABI as revealed by DW-MRI. Multivariate analysis showed that CO exposure duration > 5 hours (adjusted odds ratio [AOR] = 7.082; 95% confidence interval [CI] = 3.463-15.014; p

Preventing delayed neurological sequelae is a major goal of treating acute carbon monoxide poisoning, but to our knowledge there are no reliable tools for assessing the probability of these sequelae.To determine whether acute brain lesions on diffusion-weighted imaging are related to subsequent development of delayed neurological sequelae after acute carbon monoxide poisoning.This registry-based observational study was conducted at a university hospital in Seoul, Korea, between April 1, 2011, and December 31, 2015. Of 700 patients (aged ≥18 years) with acute carbon monoxide poisoning, 433 patients (61.9%) who underwent diffusion-weighted imaging at an emergency department were considered for the study. Patients who developed cardiac arrest before diffusion-weighted imaging (n = 3), had persistent neurological symptoms at discharge (n = 8), committed suicide soon after discharge (n = 1), and were lost to follow-up (n = 34) were excluded.The presence of unambiguous, high-signal-intensity, acute brain lesions on diffusion-weighted imaging (b = 1000 s/mm2).Development of delayed neurological sequelae defined as any neurological symptoms or signs that newly developed within 6 weeks of discharge.Of the 387 included patients (143 women [37.0%]; median age, 42.0 years [interquartile range, 32.0-56.0 years]), acute brain lesions on diffusion-weighted imaging were observed in 104 patients (26.9%). Among these, 77 patients (19.9%) had globus pallidus lesions, 13 (3.4%) had diffuse lesions, and 57 (14.7%) had focal lesions (37 patients [9.6%] had1 pattern concurrently). Lesions were supratentorial and infratentorial in 101 and 23 patients, respectively. Delayed neurological sequelae occurred in 101 patients (26.1%). Multivariable logistic regression analysis indicated that the presence of acute brain lesions was independently associated with development of delayed neurological sequelae (adjusted odds ratio, 13.93; 95% CI, 7.16-27.11; P .001). The sensitivity and specificity of acute brain lesions to assess the probability of delayed neurological sequelae were 75.2% (95% CI, 66.8%-83.7%) and 90.2% (95% CI, 86.8%-93.7%), respectively. In addition, the positive and negative predictive values were 73.1% (95% CI, 64.6%-81.6%) and 91.2% (95% CI, 87.9%-94.5%), respectively.The presence of acute brain lesions was significantly associated with the development of delayed neurological sequelae. Diffusion-weighted imaging during the acute phase of carbon monoxide poisoning may therefore help identify patients at risk of developing these debilitating sequelae.

Context: Acute kidney injury (AKI) can occur after carbon monoxide (CO) intoxication; however, limited data are available. This study aimed to evaluate the prognostic value of the development and progression of AKI in patients with acute CO poisoning. Materials and methods: We conducted a retrospective cohort study using a prospective registry of CO poisoning between January 2010 and December 2015. AKI was defined and classified according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariate logistic regression analysis was conducted to determine the association between AKI and adverse outcomes, defined as neurological deficits at discharge or 28-day mortality. Results: A total of 661 patients were evaluated. According to KDIGO criteria, 114 patients (17.2%) had AKI (initial: stage 1, 70.2%; stage 2, 26.3%; stage 3, 3.5%) on admission and 119 (18.0%) finally developed AKI during their hospital stay (maximum: stage 1, 68.9%; stage 2, 23.5%; stage 3, 7.6%). Almost all patients (99.2%) were diagnosed as having their highest KDIGO stage within three days (median, one day). AKI development was associated with adverse outcomes (odds ratio (OR) 17.53, 95% confidence interval 45.00–77.14). Both initial and maximum AKI stages demonstrated a stepwise increase of adjusted OR for adverse outcomes. AKI stage progression occurred in 8.4% of patients with AKI and was an independent factor for adverse outcomes. Conclusion: CO poisoning- related AKI occurred in 18% and was mostly detected within one day after CO intoxication. The development and progression of AKI had a strong association with adverse outcomes and deserve further prospective investigation.

Background The objective of this study was to evaluate the prognostic value of lactate levels during the first 12 hours after shock development and to identify the optimal timing for repeated lactate measurements in patients with septic shock. Methods We conducted a retrospective cohort study using a prospective data registry, and enrolled 2,226 consecutive adult patients with septic shock between January 2010 and December 2015. Blood lactate was measured at shock development, and after 2, 4, 6 and 12 hours (T0, T2, T4, T6 and T12) during protocol-driven resuscitation bundle therapy. The prognostic value of lactate levels for 28-day mortality was analyzed using logistic regression and receiver operating characteristic curve analysis. Results A total of 829 patients with septic shock were included in the study, among whom 211 died during the study period. The lactate levels at each time point were associated with increased 28-day mortality, and the lactate level at 6 hours had the greatest prognostic value (area under the curve of T0 = 0.61; T2 = 0.65; T4 = 0.69; T6 = 0.72 and T12 = 0.62, and odds ratio (OR) of T0, 1.17 [95% CI: 1.11-1.23]; T2, 1.23 [95% CI: 1.17-1.30]; T4, 1.30 [95% CI: 1.22-1.38]; T6, 1.33 [95% CI: 1.26-1.42] and T12, 1.24 [95% CI: 1.19-1.30]). Hyperlactatemia over 2 mmol/L and 4 mmol/L at 6 hours from shock was associated with 4-times higher mortality (≥2 mmol/L, OR = 3.89 [95% CI: 2.48-6.09]; ≥4 mmol/L, OR = 3.93 [95% CI: 2.83-5.44]). Conclusions During the first 12 hours following shock development, the optimal time point of repeated blood lactate measurement was 6 hours, which was the greatest prognostic value for mortality.

Background The reported mortality rate of mushroom-induced acute liver failure with conventional treatment is 1.4%–16.9%. Emergency liver transplantation may be indicated and can be the only curative treatment option. This study aimed to assess the prognostic value of criteria for emergency liver transplantation in predicting 28-day mortality in patients with mushroom-induced acute liver injury. Methods A retrospective cohort study was performed between January 2005 and December 2015. All adult patients aged≥18 years admitted with mushroom intoxication at our emergency department were evaluated. All patients with acute liver injury, defined as elevation of serum liver enzymes (>5 times the upper limit of normal, ULN) or moderate coagulopathy (INR > 2.0) were included. The ability of the King's College, Ganzert's, and Escudie’s criteria to predict 28-day mortality was evaluated. Results Of the 23 patients with acute liver injury following mushroom intoxication, 10 (43.5%) developed acute liver failure and subsequently died. The mean time interval from ingestion to death was 11.3 ± 6.6 days. Eight patients fulfilled Ganzert's criteria, while 10 patients fulfilled the King's College and Escudie’s criteria for emergency liver transplantation. King's College and Escudie’s criteria had 100% accuracy in predicting 28-day mortality; however, Escudie’s criteria were able to identify fatal cases earlier. Conclusions Escudie’s criteria demonstrated the best performance with 100% accuracy and the ability to promptly identify fatal cases of mushroom-induced acute liver failure.

Background Although the incidence of anaphylaxis is rapidly increasing, the clinical characteristics and associated factors of a biphasic reaction are unclear. Objective To determine the incidence and clinical characteristics of biphasic reactions in patients with anaphylaxis treated with corticosteroids. Methods A total of 655 patients with anaphylaxis visiting the emergency department of a tertiary teaching hospital from January 2007 through December 2014 were analyzed. Patient characteristics, triggers, symptoms and signs, in-hospital management, and disposition were recorded. A biphasic reaction was defined as the development of anaphylaxis after complete resolution of the initial reaction without further exposure to the offending agent within 7 days. Univariate and multivariate analyses on the predictors of the biphasic reaction were performed. Results Of the 415 patients with anaphylaxis treated with corticosteroids, 9 patients (2.2%) developed a biphasic reaction. The mean age was 48.4 years, and 221 patients (54.4%) were women. The median time from complete resolution of initial clinical symptoms to occurrence of the biphasic reaction was 15 hours (range 1–45). History of drug anaphylaxis (odds ratio 14.3, 95% confidence interval 2.4–85.8) was a contributing factor to the development of the biphasic reaction. Conclusion The incidence of biphasic reactions was 2.2% in patients treated with corticosteroids and those with a history of drug anaphylaxis were at greater risk.

Managing test results is an important issue in hospitals because of the increasing use of point-of-care testing (POCT). Here, we propose a smartphone-based system for automatically managing POCT test results.We developed the system to provide convenience to the medical staffs. The system recognizes the patient identification or prescription number of the test by reading barcodes and provides a countdown to indicate when the results will be ready. When the countdown in finished, a picture of the test result is transferred to the electronic medical record server using the Health Level 7 protocol. Human immunodeficiency virus (HIV) kits were selected in this research because HIV is a life-threatening infectious virus, especially for the medical staff who treat undiagnosed patients. The performance of the system was verified from a survey of the users.The performance of the system was tested at the emergency room (ER) for 10 months using commercially available POCT kits for detecting HIV. The survey showed that, in total, 80% and 0% of users reported positive or negative feedback, respectively. The staff also reported that the system reduced total processing time by approximately 32 min, in addition to reducing workload.The developed automated management system was successfully tested at an ER for 10 months. The survey results show that the system is effective and that medical staff members who used the system are satisfied with using the system at the ER.

Aspiration pneumonia is associated with significant morbidity and mortality; however, little is known about aspiration pneumonia in patients with carbon monoxide intoxication, which is the leading cause of poisoning-related death. This study aimed to evaluate the prevalence, clinical impacts, and risk factors for developing aspiration pneumonia in patients with carbon monoxide poisoning with loss of consciousness.A retrospective analysis of a carbon monoxide poisoning registry was performed at our emergency department for the period January 2008 to December 2015. All adult carbon monoxide poisoning patients with loss of consciousness were included.Aspiration pneumonia developed in 103 (19.2%) of 537 patients. It was associated with increased ventilator use (52.4% vs 3.2%), length of hospital stay (median [interquartile range], 3.6 [2.1-5.1] vs 1.3 [0.6-2.1] days), and in-hospital mortality (5.8% vs 0.0%) (all P .001). Altered mental status on emergency department arrival, white blood cell count, and increased exposure duration were the independent factors associated with development of aspiration pneumonia; odds ratios were 9.46 (95% confidence interval [CI] 4.92-18.19; P .001), 1.19 (95% CI 1.13-1.26; P .001), and 1.12 (95% CI 1.06-1.19; P .001), respectively. For painful or unresponsive mental status and white blood cell count 12,000/mmThe prevalence of aspiration pneumonia was 19.2% in carbon monoxide poisoning patients with loss of consciousness and was associated with poor outcomes. Additionally, altered mental status on emergency department arrival, white blood cell count, and increased exposure duration were independently associated with the development of aspiration pneumonia.

Neurologically intact survival after cardiac arrest is possible even after prolonged resuscitation efforts. However, the factors associated with good neurologic outcome in these patients remain unknown. This study identifies predictors associated with good neurologic outcome after resuscitation beyond 30 min in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). This multicenter, registry-based, retrospective cohort study conducted in 24 hospitals across South Korea between 2007 and 2012 includes adult (≥18 years) non-traumatic OHCA patients with prolonged (>30 min) downtime who underwent TTM treatment. Good neurologic outcomes were defined as cerebral performance category scores of ≤2. Of the 930 comatose adult cardiac arrest patients treated with TTM, 423 patients with prolonged downtime were included. A total of 76 (18.0%) had good neurologic outcome. Multivariable analysis reveal that age

The aim of this study was to evaluate the prevalence of disseminated intravascular coagulation and to determine whether the presence of disseminated intravascular coagulation is associated with major adverse events in patients with primary postpartum hemorrhage who present to the emergency department. This retrospective case-control study was conducted in the emergency department of a university-affiliated, tertiary referral center between January 1, 2004 and December 31, 2013. Patients were classified into disseminated intravascular coagulation (disseminated intravascular coagulation score ≥ 5) and non-disseminated intravascular coagulation groups. The two groups were compared in terms of clinical characteristics and the occurrence of major adverse events, defined as massive transfusion (≥ 10 units of packed red blood cells within 24 hours of emergency department admission), invasive intervention (uterine artery embolization or emergency hysterectomy), hospital days, ventilator-free days, intensive care unit admission, intensive care unit-free days, and in-hospital mortality. Among 255 patients with primary postpartum hemorrhage, 57 patients (22.4%) had overt disseminated intravascular coagulation. The disseminated intravascular coagulation group had significantly lower hemoglobin, hematocrit, platelet counts, and fibrinogen levels than the non-disseminated intravascular coagulation group; in addition, they had higher prothrombin times, and D-dimer levels (P

Objective This study aimed to examine trends in the incidence and outcomes of bicycle-related injuries in emergency departments (ED) in South Korea. Methods We analysed data from the National Emergency Department Information System database for adult patients (≥20 years) with bicycle-related injuries presenting to EDs in South Korea between January 2012 and December 2014. Riders and bicycle passengers whose injuries were associated with bicycle use were included. Serious outcomes were defined as death at the ED, need for emergency operation, or intensive care unit admission. Results The number of people who commute to work by bicycle increased by 36% from 205,100 in 2005 to 279,544 in 2015. Of 529,278 traffic-related trauma cases, 58,352 (11.0%) were bicycle-related, which increased from 7,894 (10.2%) in the first half of 2012 to 12,882 (12.2%) in the second half of 2014 (p < 0.001). However, the proportion of serious outcomes decreased from 5.0% to 4.2% during the study period (p < 0.001). Serious outcomes were most frequent in the elderly (65–74 years) and older elderly (≥75 years) groups and decreased for all but the elderly age group from 10.3% to 9.8% (p = 0.204). The helmet use rate increased from 14.2% to 20.3% (p < 0.001) but was the lowest in the older elderly group (3.6%) without change during the study period (from 4.7% to 3.7%, p = 0.656). A lack of helmet use was significantly associated with serious outcomes (odds ratio, 1.811; 95% confidence interval, 1.576–2.082). Conclusions Although the incidence of bicycle-related injuries increased, the proportion of serious outcomes decreased, possibly due to increased helmet use. Public education on safety equipment use is required, especially in elderly populations.

The aim of this study was to assess whether delayed resuscitation bundle compliance from 6 to 12 h after a diagnosis of septic shock has an impact upon 28-day mortality. A prospective observational study on consecutive adult patients with septic shock was performed in the Emergency Department (ED) of a tertiary care university-affiliated hospital between January 2010 and July 2012. Compliance with the resuscitation bundle was assessed at 6 and 12 h after a septic shock diagnosis (time 0). Patients were divided into three groups: early compliance (≤6 h), delayed compliance (>6 but ≤12 h), and non-compliance (>12 h). The 28-day mortality was compared among the groups. A total of 332 patients were included, with an overall 28-day mortality of 17.2 %. The mean age was 63.9 years; 57.8 % were men. Early compliance was achieved in 195 patients (58.7 %), delayed compliance in 59 patients (19.8 %), and non-compliance in 78 patients (23.5 %). The groups did not differ in baseline sequential organ failure assessment illness severity. However, the non-compliance group had a significantly higher mortality (29.5 %) than the delayed-compliance (13.6 %) and early-compliance (13.3 %) groups (p = 0.04). Delayed compliance was associated with a lower mortality risk than non-compliance (adjusted odds ratio 0.32, 95 % confidence interval: 0.13–0.82, p = 0.02). In conclusion, if bundle therapy be started at the time of presentation, the outcome of delayed resuscitation bundle compliance within 12 h is same as that of early resuscitation bundle compliance within 6 h, and these are better than that of the patients who had late or no compliance.

Objectives The diagnosis of acute pulmonary embolism (PE) in trauma patients is challenging. This study evaluated the diagnostic value of simplified Wells and simplified revised Geneva scores to predict PE in femur fracture patients in emergency department (ED). Methods All consecutive adult patients with femur fractures and elevated D-dimer levels (> 0.5 μg/mL) who underwent CTPA within 72 h of injury from January 2010 to December 2014 were included. The simplified Wells and simplified revised Geneva scores were applied to evaluate the clinical probability of PE. Results Among 519 femur fracture patients, 446 patients were finally included, and 23 patients (5.2%) were diagnosed with acute PE. The median values of simplified Wells and simplified revised Geneva scores [0 (IQR: 0–1) vs. 0 (IQR: 0–0), P = 0.23; 3 (IQR: 2–4) vs. 3 (IQR: 2–3), P = 0.48] showed no differences between the PE (n = 23) and non-PE (n = 423) groups. Using the simplified Wells score, 98% of the patients were categorized into the “PE unlikely” group. The sensitivity, specificity, positive predictive value, and negative predictive value of the simplified revised Geneva score (≥ 3 points) for the diagnosis of PE were 74%, 35%, 6%, and 96%, respectively. Conclusion In femur fracture patients with elevated D-dimer levels, the simplified Wells and simplified revised Geneva scores have limited predictive value. However, the simplified revised Geneva score of

Construction workers are exposed to a wide variety of health hazards such as poisoning at the construction sites. Various forms of poisoning incidents in construction workers have been reported. However, studies on methemoglobinemia caused by unintentional ingestion of antifreeze admixtures containing sodium nitrite at the construction sites have not been reported yet.The aim of this study was to evaluate life-threatening methemoglobinemia after unintentional ingestion of antifreeze admixtures containing sodium nitrite at the construction sites and describe similar incidents involving ingestion of antifreeze admixtures in Korea.Retrospective observational case series study on patients with methemoglobinemia after unintentional ingestion of antifreeze admixtures containing sodium nitrite admitted to the emergency department (ED) from January 1, 2010 to December 31, 2012 and cases reported to the Korea Occupational Safety and Health Agency (KOSHA) was performed. Results. Six victims were admitted to our ED. They had methemoglobin levels ranging from 32.4% to 71.5% and all of them recovered after receiving one (2 mg/kg) or two doses infusion of methylene blue. From the data of the KOSHA, six incidents that caused 27 victims were identified. Of 27 victims, five were included in the ED cases. For all incidents, antifreeze admixtures were not contained in their original containers and all new containers did not have a new label. All workers mistook antifreeze admixtures for water. Among the 28 victims included in this study, four died.Unintentional ingestion of antifreeze admixtures containing sodium nitrite at the construction sites can cause life-threatening methemoglobinemia. There is a need to store and label potentially hazardous materials properly to avoid unintentional ingestion at the construction sites.

Direct laryngoscopy using a Macintosh laryngoscope is the most widely used approach; however, this skill is not easy for novices and trainees. We evaluated the performance of novices using a laryngoscope with a three-dimensional (3D)-printed ergonomic grip on an airway manikin. Forty second-year medical students were enrolled. Endotracheal intubation was attempted using a conventional Macintosh laryngoscope with or without a 3D-printed ergonomic support grip. Primary outcomes were intubation time and overall success rate. Secondary outcomes were number of unsuccessful attempts, first-attempt success rate, airway Cormack-Lehane (CL) grade, and difficulty score. In the easy airway scenario, intubation time, and the overall success rate were similar between two group. CL grade and ease-of-use scores were significantly better for those using the ergonomic support grip (P < 0.05). In the difficult airway scenario, intubation time (49.7±37.5 vs. 35.5±29.2, P = 0.013), the first-attempt success rate (67.5% vs. 90%, P = 0.029), number of attempts (1.4±0.6 vs. 1.1±0.4, P = 0.006), CL grade (2 [2, 2] vs. 2 [1, 1], P = 0.012), and ease-of-use scores (3.5 [2, 4] vs. 4 [3, 5], P = 0.008) were significantly better for those using the ergonomic support grip. Linear mixed model analysis showed that the ergonomic support grip had a favorable effect on CL grade (P

The aims of this study were to evaluate the clinical characteristics and outcomes of patients with grayanotoxin poisoning due to mad honey brought from Nepal. Medical records of patients with mad honey poisoning admitted to the emergency department between 1 January 2004 and 31 May 2012 were retrospectively reviewed. A total of 15 patients were included in this study. In all patients, mad honey was brought from the Himalayan region of Nepal. The mean age was 52.2 years, and 66.7 % were men. The mean amount of mad honey ingested was 47 cc, and the mean time from ingestion to onset of symptoms was 36 min. In all patients, initial vital signs showed hypotension and bradycardia. The initial electrocardiogram showed sinus bradycardia in eight patients, junctional bradycardia in four patients, complete atrioventricular block in two patients, and atrial fibrillation with slow ventricular response in one patient. Four patients were treated with intravenous normal saline solution only. Eleven patients were treated with intravenous normal saline solution and intravenous atropine sulfate in a dose ranging from 0.5 to 2.0 mg. In all patients, the blood pressure and pulse rate returned to normal limits within 24 h. There were no deaths. The clinical characteristics and outcome of grayanotoxin poisonings caused by the ingestion of mad honey from Nepal are similar with those of mad honey from the Black Sea region of Turkey.

The aim of this study was to determine whether initial shock index (SI) was independently associated with the requirement for massive transfusion (MT) in emergency department (ED) patients with primary postpartum hemorrhage (PPH). A retrospective cohort study of ED patients with primary PPH was performed at a university-affiliated, tertiary referral center between January 2004 and May 2012. Patients were classified to two groups: MT group (patients who received ≥10 U of packed red blood cells within 24 h of ED admission) and non-MT group (patients who received

In Sepsis-3, the quick Sequential Organ Failure Assessment (qSOFA) score was developed as criteria to use for recognizing patients who may have poor outcomes. This study was performed to evaluate the predictive performance of the qSOFA score as a screening tool for sepsis, mortality, and intensive care unit (ICU) admission in patients with febrile neutropenia (FN). We also tried to compare its performance with that of the systemic inflammatory response syndrome (SIRS) criteria and Multinational Association of Supportive Care in Cancer (MASCC) score for FN. We used a prospectively collected adult FN data registry. The qSOFA and SIRS scores were calculated retrospectively using the preexisting data. The primary outcome was the development of sepsis. The secondary outcomes were ICU admission and 28-day mortality. Of the 615 patients, 100 developed sepsis, 20 died, and 38 were admitted to ICUs. In multivariate analysis, qSOFA was an independent factor predicting sepsis and ICU admission. However, compared to the MASCC score, the area under the receiver operating curve of qSOFA was lower. qSOFA showed a low sensitivity (0.14, 0.2, and 0.23) but high specificity (0.98, 0.97, and 0.97) in predicting sepsis, 28-day mortality, and ICU admission. Performance of the qSOFA score was inferior to that of the MASCC score. The preexisting risk stratification tool is more useful for predicting outcomes in patients with FN.

The Middle East respiratory syndrome coronavirus (MERS-CoV) was exported to Korea in 2015, resulting in a threat to neighboring nations. We evaluated the possibility of using a digital surveillance system based on web searches and social media data to monitor this MERS outbreak. We collected the number of daily laboratory-confirmed MERS cases and quarantined cases from May 11, 2015 to June 26, 2015 using the Korean government MERS portal. The daily trends observed via Google search and Twitter during the same time period were also ascertained using Google Trends and Topsy. Correlations among the data were then examined using Spearman correlation analysis. We found high correlations (>0.7) between Google search and Twitter results and the number of confirmed MERS cases for the previous three days using only four simple keywords: “MERS”, “"Equation missing"” (“MERS (in Korean)”), “"Equation missing"” (“MERS symptoms (in Korean)”), and “"Equation missing"” (“MERS hospital (in Korean)”). Additionally, we found high correlations between the Google search and Twitter results and the number of quarantined cases using the above keywords. This study demonstrates the possibility of using a digital surveillance system to monitor the outbreak of MERS.

To determine the relationship between acid–base findings, such as pH, pCO2, and serum lactate levels, obtained immediately after starting cardiopulmonary resuscitation and the return of spontaneous circulation (ROSC). A prospective observational study of adult, nontraumatic out-of-hospital cardiac arrest (OHCA) patients was conducted at an urban academic teaching institution between April 1, 2013 and March 31, 2015. Arterial blood sample for acid–base data was taken from all OHCA patients on arrival to the emergency department. Of 224 OHCA patients, 88 patients with unavailable blood samples or delayed blood sampling or ROSC within 4 minutes were excluded, leaving 136 patients for analysis. The pH in the ROSC group was significantly higher than in the non-ROSC group (6.96 vs. 6.85; P = 0.009). pCO2 and lactate levels in the ROSC group were significantly lower than those in the non-ROSC group (74.0 vs. 89.5 mmHg, P

Introduction and Objectives We aimed to develop a new prediction model of mortality in cancer patients with pneumonia and to compare its performance with CURB-65 and the Pneumonia Severity Index (PSI). Methods Active cancer patients who were diagnosed with pneumonia at the Emergency Department (ED) from 7/1/2014 to 12/31/2014 were consecutively included. Clinical data were collected through a medical chart review. The primary outcome was the 28-day mortality, and clinical factors were analyzed using logistic regression analysis. Results Among a total of 218 analyzed patients with a median age of 64.0 years (IQR, 56.8-71.0) and a male proportion of 72%, 42 (19.3%) died within 28 days of ED admission. By multivariate logistic regression analysis, an ECOG performance status (PS) 3 (OR: 8.54, 95% CI: 3.42-21.33) or 4 (OR: 13.17, 95% CI: 3.19-54.32), SpO2

Background Femur fracture is a well-recognized risk factor for pulmonary embolism (PE). Despite recent reports of early PE after major trauma, the incidence and outcomes of PE in femur fracture patients are unknown. The aims of the study were to determine the incidence of PE after a femur fracture and to evaluate its timing and clinical significance. Methods We included all consecutive adult patients (≥18 years old) with femur fracture admitted to our emergency department from January 2010 to December 2014 who underwent subsequent PE computed tomography within 72 hours. Of 453 stable patients, 28 with a confirmed diagnosis of acute PE were compared against those without PE. Results Of 1,301 femur fracture patients who presented at our hospital, 453 were included in our present analysis, of whom 28 developed PE (2.2%). Proximal PE, defined as emboli located within the main or lobar arteries, constituted 78.6% and subsegmental PE constituted 21.4% of these 28 cases. The femur fracture sites were mainly intertrochanteric (50.3%) and the neck (43.9%). The median interval from injury to computed tomography was 13.0 hours (IQR, 9.0-24.0 hours). PE was detected in 57.1% (16 of 28) of patients in the first 24 hours after injury and in 89.3% (25 of 28) in the first 48 hours. Overall mortality was 0.7%, and no patient in the early PE group died of their injury. Conclusion PE arises in femur fracture patients in the immediate period following injury and shows an incidence somewhat higher than commonly appreciated in other trauma events but is not fatal. Level of evidence Epidemiologic/prognostic study, level III.

Although adrenaline (epinephrine) is a cornerstone of initial anaphylaxis treatment, it is not often used. We sought to assess whether use of adrenaline in hemodynamically stable patients with anaphylaxis could prevent the development of hypotension. We conducted a retrospective cohort study of 761 adult patients with anaphylaxis presenting to the emergency department (ED) of a tertiary care hospital over a 10-year period. We divided the patients into two groups according to the occurrence of hypotension and compared demographic characteristics, clinical features, treatments and outcomes. Of the 340 patients with anaphylaxis who were normotensive at first presentation, 40 patients experienced hypotension during their ED stay. The ED stay of the hypotension group was significantly longer than that of patients who did not experience hypotension (496 min vs 253 min, P = 0.000). Adrenaline use in hemodynamically stable anaphylaxis patient was independently associated with a lower risk of developing in-hospital occurrence of hypotension: OR, 0.254 [95% CI, 0.091–0.706]. Adrenaline use in hemodynamically stable anaphylaxis patients was associated with a reduced risk of developing in-hospital occurrence of hypotension. Adverse events induced by adrenaline were rare when the intramuscular route was used.

Background Digital surveillance using internet search queries can improve both the sensitivity and timeliness of the detection of a health event, such as an influenza outbreak. While it has recently been estimated that the mobile search volume surpasses the desktop search volume and mobile search patterns differ from desktop search patterns, the previous digital surveillance systems did not distinguish mobile and desktop search queries. The purpose of this study was to compare the performance of mobile and desktop search queries in terms of digital influenza surveillance. Methods and results The study period was from September 6, 2010 through August 30, 2014, which consisted of four epidemiological years. Influenza-like illness (ILI) and virologic surveillance data from the Korea Centers for Disease Control and Prevention were used. A total of 210 combined queries from our previous survey work were used for this study. Mobile and desktop weekly search data were extracted from Naver, which is the largest search engine in Korea. Spearman's correlation analysis was used to examine the correlation of the mobile and desktop data with ILI and virologic data in Korea. We also performed lag correlation analysis. We observed that the influenza surveillance performance of mobile search queries matched or exceeded that of desktop search queries over time. The mean correlation coefficients of mobile search queries and the number of queries with an r-value of ≥ 0.7 equaled or became greater than those of desktop searches over the four epidemiological years. A lag correlation analysis of up to two weeks showed similar trends. Conclusion Our study shows that mobile search queries for influenza surveillance have equaled or even become greater than desktop search queries over time. In the future development of influenza surveillance using search queries, the recognition of changing trend of mobile search data could be necessary.

Objective We tried to evaluate the accuracy of the heel drop test in patients with suspected appendicitis and tried to develop a new clinical score, which incorporates the heel drop test and other parameters, for the diagnosis of this condition. Methods We performed a prospective observational study on adult patients with suspected appendicitis at two academic urban emergency departments between January and August 2015. The predictive characteristics of each parameter, along with heel drop test results were calculated. A composite score was generated by logistic regression analysis. The performance of the generated score was compared to that of the Alvarado score. Results Of the 292 enrolled patients, 165 (56.5%) had acute appendicitis. The heel drop test had a higher predictive value than rebound tenderness. Variables and their points included in the new (MESH) score were pain migration (2), elevated white blood cell (WBC) >10,000/μL (3), shift to left (2), and positive heel drop test (3). The MESH score had a higher AUC than the Alvarado score (0.805 vs. 0.701). Scores of 5 and 11 were chosen as cut-off values; a MESH score ≥5 compared to an Alvarado score ≥5, and a MESH score ≥8 compared to an Alvarado score ≥7 showed better performance in diagnosing appendicitis. Conclusion MESH (migration, elevated WBC, shift to left, and heel drop test) is a simple clinical scoring system for assessing patients with suspected appendicitis and is more accurate than the Alvarado score. Further validation studies are needed.

Aim The main treatment goal in survivors of out-of-hospital cardiac arrest (OHCA) is a favorable neurologic outcome. Little is known, however, about long-term trends of neurologic status in OHCA survivors. This study was designed to assess the rates of long-term neurologic recovery and survival according to neurologic status at one month. Methods This retrospective observational study assessed all adult OHCA survivors (≥18years) admitted to a tertiary hospital in an urban area who achieved return of spontaneous circulation (ROSC) between July 2005 and August 2013. Neurologic outcomes were measured by Cerebral Performance Category (CPC) score and patients were categorized according to CPC score at 1 month. Their neurologic status was re-evaluated 6, 12, and 24 months after cardiac arrest. Results Of 778 OHCA cases, 282 patients (36.2%) were admitted to our hospital, and 279 were included in this study. At one month, 84 (30.1%) survivors were assessed with the CPC with 42.8% ( n =36) having good neurologic outcome and 57.1% ( n =48) poor neurologic outcome. Only two patients with poor neurologic outcome (4.1%) showed improved neurologic status from CPC 3 to CPC 2, during the first 6 months and none showed neurologic improvement after 6 months. The estimated 3-year survival was much higher for CPC 1 (96.4%) than for CPC 4 (24.2%) survivors. Conclusions Neurologic recovery of OHCA survivors with poor neurologic outcomes at one month was rare and did not occur more than 6 months after cardiac arrest.